The complexity of care required for patients with multiple long-term conditions, both physical and mental, can make it difficult for one clinician to have the breadth of knowledge, experience or time to provide the level of care required. The solution: practice teams with an increasingly diverse skillset. So, let’s look at paramedics as practitioners and the role they can play in general practice and what they can add to the multidisciplinary mix.
The merits of diversity
“The NHS Alliance is an advocate of multidisciplinary working,” Dr Mark Spencer, co-chair of the NHS Alliance, medical director of FCMS and GP in Fleetwood, Lancashire, tells us. This concept, he adds, extends beyond traditional models comprising GPs and nursing staff to include clinical pharmacists, dentists and paramedics, for example.
Contemporary medical needs require a more specialised primary care frontline in order to treat patients with multiple, acute illnesses effectively – and a diverse primary care team is best-equipped to deal with this. For example, in cases where patients suffer numerous conditions, and are prescribed multiple medicines, a clinical pharmacist might be best placed to offer care; they can review and monitor medication, explain how to administer the medicines and, perhaps, provide more holistic care.
There are, of course, points to be considered when establishing a multidisciplinary team. Dr Spencer draws attention to the importance of education and training, especially where caregivers are not experienced in working in a practice. There is also indemnity to consider; looking at responsibilities and roles, protocols and procedures, as well as asking where the risk lies. These issues are easily overcome and ironing out such concerns is well worthwhile.
Paramedics in practice
Paramedics bring much-needed services to the multidisciplinary team; one such is home visiting. “A considerable amount of a GP’s time is taken up by home visits and much of that time is non-clinical, spent travelling from house to house; for paramedics, that’s their bread and butter,” Dr Spencer observes. At his own practice in Fleetwood they benefit from a paramedic practitioner who carries out the majority of home visits, something Dr Spencer says frees up a phenomenal amount of GP time, reducing GP stress and often providing a much quicker response to patient needs.
The paramedic is never alone on such visits; support is always at hand as EMIS Web means paramedics have GP records on their tablet, at the scene. Whereas, previously, paramedics would be reliant on the patient to inform them of the problem, they now have access to a full medical history. “And that’s live. It’s as though they are sat in the GP practice with their medical record. We can also establish video links with the practice in the patient’s home so you can have a three or four-way conversation between GP, paramedic, patient and carer.”
Many paramedics also undertake minor ailment clinics, enabling requests for urgent appointments to be streamed into paramedic surgeries – spreading the workload and alleviating pressure. Plus, practices are now developing ‘anticipatory care plans’ – a process designed to support patients living with a chronic long-term condition to help plan for an expected change at some time in the future. Ambulance paramedics are one of the recipients of these plans and having these written by practitioner paramedics means they are more easily understood by their ambulance counterparts. This, Dr Spencer says, is a step forward.
Delivering rapid response primary care
Encompass is a multispecialty community provider (MCP) vanguard that serves 170,000 patients across Whitstable, Faversham, Canterbury, Ash and Sandwich and represents 122 GPs from 15 general practices. The MCP recently rolled out a paramedic practitioner scheme across its remit following a successful trial which saw roughly 15% fewer hospital transfers, a more rapid response for patients and high levels of patient satisfaction.
“The idea was to have a paramedic practitioner team, attached to general practices, taking selected calls triaged by GPs and being the first responder to what was, initially, a request for a GP visit,” explains Dr John Ribchester, clinical lead and chair of Encompass and senior and executive partner of Whitstable Medical Practice. The scheme delivers a quicker response time, alleviates pressure on GPs and prevents patients from unnecessarily defaulting to the hospital.
Encompass divides its area into community hubs with patient populations of between 30,000 and 60,000, each served by a single vehicle. Practices refer directly to the paramedic, each with an equitable portion of all calls to the paramedic service. Dr Ribchester says that the scheme has been very successful. “They’re doing about 30% more calls than originally anticipated.” (See fig.1)
The scheme has improved integration between paramedics and the primary care team. “For the first time, paramedics in our area feel part of an extended primary care team rather than just ‘the ambulance driver’,” Dr Ribchester observes. As in Fleetwood, paramedics here are fully supported on home visits by having the relevant GP electronic record present. “Having the patient record to hand makes a big difference to the decision-making process,” says Dr Ribchester. “They are seeing the patient and the patient record together.”
Paramedics can play an integral role in delivering better patient outcomes and, as Dr Ribchester notes, give general practice some much needed headspace. “General practice, in most of the country, is under pressure. A GP delegating even one or two visits to a paramedic can free-up time for everything else they must do.”
Education and training:
Dr Spencer’s paramedics undertake the nurse practitioner course which he says is the ideal format for their education and training.
Paramedics are not able to undertake their prescribing qualifications at present, something Dr Spencer says needs to be addressed as a matter of urgency.
A review of the pilot revealed:
Two-thirds of patients visited had their care needs met by the paramedic
10% were taken into hospital because their condition warranted it
For 25% of patients, the paramedic was able to consult the GP via a designated hotline and discuss a care plan and further treatment.